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MEDITECH INSTRUCTIONS: 1. Click “Enter New” (on the right-hand navigation menu) 2. Search “Student History & Physical,” add to favorites 3. Click “Add Section” (on the right-hand navigation menu)  search “History & Physical – blank,” add to favorites 4. Copy & paste the template below into the “H&P-BLANK” section of your note 5. Press F2 on the keyboard to tab through all the parts of the history that need to be changed for your individual patient 6. Click “Quick Save” H&P for Triage Patient CHIEF COMPLAINT: HPI: [] yo G[]P[] at [] []/7 WGA by last menstrual period consistent with [] week ultrasound who presents to labor and delivery triage with []. Patient denies vaginal bleeding []loss of fluids, []reports active fetus. Prenatal care complicated by []diabetes []hypertension Patient has been receiving prenatal care at [] with Dr. []. Estimated due date []. Last menstrual period []. OB HISTORY: G1 []year []vaginal or c/s at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia G2 []year []vaginal or c/ at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia G3 []year []vaginal or c/s at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia G4 []year []vaginal or c/s at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia GYN HISTORY: Menses: Age at menarche [], [] regular every month lasts [] days STDs: patient reports [] no history of STI’s, [] consistent with chart review Abnormal Paps: [] no documented abnormal pap smears, patient denies PMH: [] PSH: [] FAMILY HISTORY: []no family history of birth defects or genetic disorders SOCIAL HISTORY: [] no tobacco, no alcohol, no drugs MEDICATIONS: []prenatal vitamins ALLERGIES: [] ([]rash, []anaphylaxis) ROS: [] all systems reviewed and negative except as noted in HPI. PHYSICAL EXAM: Vital signs reviewed [] (ENTER “VITAL SIGNS - LAST 24 HR RANGE” AND “VITAL SIGNS - FIRST DOCUMENTED” HERE - click “Data Formats” on right-hand menu & search for these) Gen: []alert and awake HEENT: []normocephalic, no periorbital edema CV: []well perfused Resp: []aerating well, symmetric expansions Abd: []soft gravid, fundal height appropriate Extremities: []no clubbing, no cyanosis, []trace edema on lower extremities Pelvic: []adequate pelvis, EFW[] Cervix: [] Skin: []supple, intact, no rashes MEDICAL DECISION MAKING: Prenatal Labs: []blood type, []RI, []RPRNR, []HIV-, []HBV-, []HCV-, []GC/CT-, []1-GTT, []Pap normal, []GBS- External Fetal Heart Rate Monitor: [] baseline HR [] with moderate variability, [] no decelerations Tocometry: [] contractions Bedside U/S: [] [] ENTER “ALL LAB/MICRO/RAD LAST 16 HRS” AND “CBC-FISHBONE ONLY” HERE – click “Data Formats” on right-hand menu & search for these ASSESSMENT: 1) [] yo G[]P[] at [] []/7 WGA by LMP c/w [] weeks ultrasound here for []. 2) Not in active labor 3) Reassuring fetal status 4) Cephalic presentation 5) GBS[] PLAN: (KEEP THIS IF PT IS DISCHARGED FROM TRIAGE) - Discharge to home - Labor precautions reviewed - Pre-eclampsia precautions discussed - Follow up with primary obstetrician - Red flags to call MD or return to hospital discussed with patient who voiced understanding - Plan of care reviewed with patient and questions answered. - Patient care plan discussed with attending physician, Dr. [] PLAN: (KEEP THIS IF PT IS ADMITTED FROM TRIAGE) - Admit to Labor & Delivery. (If patient is less than 39 wga, the indication for delivery is [] and the patient was counseled on the slightly increased risk of fetal morbidity/mortality at this gestational age, however, the benefits of delivery prior to 39 weeks outweigh the risks at this time.) - Consent obtained - Admit labs drawn - Fetal heart rate and contraction monitoring - Start pitocin as clinically indicated - Consult anesthesia for epidural as requested by patient - Labor & delivery course discussed with patient; questions answered - Patient care plan discussed with attending physician Dr. []